Form 80-107-13-8-1-000 - Income / Withholding Tax Schedule - 2013

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Mississippi
Form 80-107-13-8-1-000 (Rev. 12/13)
Print Form
Income / Withholding Tax Schedule
2013
801071381000
Primary Taxpayer's Name (As shown on Forms 80-105, 80-110, 80-205 and 81-110)
1
A - Statement Information
B - Income and Withhholding
C - Employer or Payer Information
Check appropriate box
.
W-2
1099
K-1
MS
00
State
Mississippi Taxable Income
Employer or payer name
If 1099-R, Code in Box 7
.
Address
00
Employer or payer ID from W-2, 1099, K-1
Mississippi Withholding Only
City, State, ZIP
.
Taxpayer Name
00
State
Income from Other State
Taxpayer Social Security Number
2
A - Statement Information
B - Income and Withhholding
C - Employer or Payer Information
Check appropriate box
.
W-2
1099
K-1
MS
00
State
Mississippi Taxable Income
Employer or payer name
If 1099-R, Code in Box 7
.
Address
00
Employer or payer ID from W-2, 1099, K-1
Mississippi Withholding Only
City, State, ZIP
Taxpayer Name
.
00
State
Income from Other State
Taxpayer Social Security Number
3
A - Statement Information
B - Income and Withhholding
C - Employer or Payer Information
Check appropriate box
.
W-2
1099
K-1
MS
00
State
Mississippi Taxable Income
Employer or payer name
If 1099-R, Code in Box 7
.
Address
00
Employer or payer ID from W-2, 1099, K-1
Mississippi Withholding Only
City, State, ZIP
Taxpayer Name
.
00
State
Income from Other State
Taxpayer Social Security Number
4
A - Statement Information
B - Income and Withhholding
C - Employer or Payer Information
Check appropriate box
.
W-2
1099
K-1
MS
00
State
Mississippi Taxable Income
Employer or payer name
If 1099-R, Code in Box 7
.
Address
00
Employer or payer ID from W-2, 1099, K-1
Mississippi Withholding Only
City, State, ZIP
Taxpayer Name
.
00
State
Income from Other State
Taxpayer Social Security Number
THIS FORM MUST BE FILED EVEN IF YOU HAVE NO MISSISSIPPI WITHHOLDING
Duplex and Photocopies NOT Acceptable

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